Seroprevalence of HIV infection among the patients attending various emergency departments in a tertiary care hospital

Emergency departments (EDs) receive patients from every background, socioeconomic group and health status. Hence, EDs can play a critical role in offering human immunodeficiency virus (HIV) testing and help in the national strategy of early HIV detection. The present study was conducted on 400 patients attending various EDs after taking Institutional Review Board approval. They were screened for HIV antibodies by three rapid/simple assay tests having different principles/antigens as per the NACO guidelines. Twenty-three (5.75%) of the 400 patients were HIV reactive. Fifteen (65.22%) of the 23 HIV-reactive patients were unaware of their reactive status. Majority of the HIV-reactive (65.22%) patients were from the Medicine emergency followed by Orthopaedics and Surgery (13.04%). Seven (30.43%) had history of fever of more than 1 month duration. Eight (34.78%) of them were later on clinically diagnosed as having various opportunistic infections. Thus, the study emphasizes the need for expansion of routine voluntary HIV counseling and testing to all the patients who come to the ED and practicing universal work precautions by health care workers.


INTRODUCTION
The emergency department (ED) is an ideal place for public health interventions and provides ready access to the health care system, offering a great opportunity for human immunodeficiency virus (HIV) testing and counselling.
EDs receive patients from every background, socioeconomic group and health status. Hence, EDs are a key component of the health care safety net. Patients not linked with health services are particularly likely to seek care in an ED when medical concern arises. [1] However, it has been seen that HIV infection is diagnosed most of the times with one or the other opportunistic infection (OI), particularly in developing countries. At the time of diagnosis, most of the patients have advanced disease and are at a higher risk of OIs and death.
Emergencies in HIV-infected patients can occur at any stage of the disease. EDs can play a critical role in offering HIV testing and help in the national strategy of early HIV detection. Early detection will allow the infected individuals to take full advantage of Anti retroviral therapy (ARTs) and preventive medicines for opportunistic infections. [2] Emergency medical personnel must assiduously guard against accidental needle stick injury by practicing universal work precautions (UWPs) strictly as they present the greatest risk for health care work-related HIV infection. [3]

RESULTS
Of the 400 patients in the study group, 23 (5.75%) were found to be HIV reactive, as shown in Table 1. Fifteen (65%) of the 23 HIV-reactive patients were not aware of their HIV infection.
HIV seroreactivity with respect to sex, age, occupation and marital status of the 400 patients under study group is shown in Table 1. Twenty-one (91.30%) of the 23 HIV-reactive patients were in the age group <40 years, while only two (8.69%) were >40 years old. The difference in the incidence of HIV among the different age groups is statistically significant (P = 0.0175).
HIV infection among the people of different occupations is shown in Table 1. Of eight truck drivers, five (62.5%) were HIV positive (P < 0.001) and thus the difference is statistically significant.
Various risk factors associated with the HIV-reactive patient are shown in Table 2. ED-wise distribution of 400 cases and the percentage of HIV seropositivity among the patients of different departments is shown in Table 3.
Various emergencies present in HIV-reactive patients in various EDs are shown in Table 4.

DISCUSSION
In serological surveys conducted by the Centre for Disease Control (CDC), Atlanta, 0.2-8.9% of the patients seeking emergency care and 0.1-7.8% of the patients receiving acute care were found to be HIV antibody positive. Sixty-three to 65% of these patients were unaware of their HIV status. [4] In India, Teja et al, have reported an incidence of 2.95% in EDs. [2] Many other studies have shown that ED can play a major role in the diagnosis of HIV infection. [5] In 2001, the CDC had issued guidelines giving explicit emphasis to the role of emergency physicians, owing to the realization that the ED represents the only source of medical care for many patients and often serves as the primary site for routine health care to communities at risk for HIV. [6] A high number of patients (65.22%) in our study were unaware of their infection, which might be because of the reason that the people in routine do not need to go for HIV testing on their own without the onset of serious symptoms. It is evident that ED can play a critical role in offering HIV testing and help in the National Strategy of early detection and further prevention programmes. [7] As the HIV seropositivity rate in emergency patients is alarmingly high in the present study, there is the need of early diagnosis of primary HIV infection, which represents an important opportunity to prevent transmission to others as, in the early stages of the disease, patients have high levels of viremia, which, coupled with a lack of awareness, can lead to transmission to family and others. [2] Early detection of primary HIV infection will also help the HIV-reactive patients in starting their treatment in time. This will also help health care personnel to understand the importance of practicing UWPs while rendering care to patients to prevent transmission of HIV infection, particularly inexperienced junior residents practicing emergency medicine in an environment that is often frenetic.
HIV testing should be integrated with screening for other infections such as viral hepatitis, sexually transmitted diseases and tuberculosis. Because populations disproportionately affected by HIV are also disproportionately affected by these infections, integrating these services can significantly improve health care services.
Thus, the study emphasizes the importance of offering rapid HIV testing to all patients who present in the ED with or without symptoms. Routine testing might increase the linkage of HIV-positive persons to health and prevention services earlier in the course of infection, which might result in improved longterm prognosis and reduced HIV transmission.